Thursday, April 4, 2013

Brinksmanship

I hate it when I think of the best retort ten minutes after the conversation has ended...

She had enough. Her son said many times that he didn't want to live this way. Intubated, disfigured with tubes and lines, and riddled with small satellites of cancer throughout his body, he was no longer recognizable. Her voice was unwavering.

Remove the tube.

It was the right decision even though there were signs of improvement. The last vestiges of sepsis had pushed the kidneys into oblivion. The lungs moaned against the ventilator and refused to open. Yet the fever had resolved and the white count was trending back towards normal.

I huddled with the staff and prepared the orders for the morphine and ativan drips. I finished my note and turning the corner, I almost ran smack into the oncologist. She had seen my charting on the EMR, and rushed over to talk to the mother. She was hoping to convince her otherwise. She addressed me before she entered the room.

How come we push people off the building with chemo and then pull away the safety net right as they are hurdling towards the ground and need us the most? Withdraw care? He is just starting to improve!

I was so stunned, I didn't know how to answer. Minutes later the mother shook her head as she listened. She reasoned out loud.

So we pull him from the brink, what then? How are you going to fix the rest?

The oncologist left the room and returned to her clinic, beaten but resigned. The breathing tube would be removed despite her objections.

Sitting in my office moments later, I couldn't help but think the oncologist had it all wrong. Dying from cancer can be like falling off a building. Without interference, one dies instantaneously, no harm no foul. But sometimes we doctors pull out our flimsy tarp at the last minute.

The canvas defies acceleration and hinders death briefly, but doesn't fully cushion the fall. Bones break and vertebrate snap.

The miserable soul then lies prostrate for days on a ventilator in the ICU.